Internal Medicine - New Patient

Reason for Referral: John Doe, a 45-year-old male, was referred by Dr. Sarah Smith for evaluation of persistent fatigue and weight loss. History of Presenting Illness: John Doe has been experiencing fatigue and unintentional weight loss over the past three months. He reports no fever, night sweats, or changes in appetite. He was previously diagnosed with hypertension and is currently on medication. He works as an accountant, smokes occasionally, consumes alcohol socially, and has comprehensive health insurance. Past Medical History: John has a history of hypertension diagnosed five years ago and underwent an appendectomy at age 30. Medications: John is currently taking Lisinopril 10 mg once daily for hypertension. Family History: John's father had a history of coronary artery disease, and his mother has type 2 diabetes. Physical Examination: Vital signs are stable with a blood pressure of 130/85 mmHg, heart rate of 78 bpm, and temperature of 36.8°C. Physical examination reveals no abnormalities in the cardiovascular, respiratory, or gastrointestinal systems. Investigations: Recent blood tests show a hemoglobin level of 13.5 g/dL, white blood cell count of 6,000/mm³, and normal liver function tests. A stress test was completed, showing a resting heart rate of 78 bpm, maximum heart rate of 150 bpm, total time of 10 minutes, 10 METs, no ST changes, and a normal resting EKG. Summary: Discussed the potential causes of fatigue and weight loss with John, including lifestyle factors and possible underlying conditions. Advised on dietary changes and the importance of regular exercise. Referred to a dietitian for further evaluation. Plan to follow up in four weeks. Plan: 1. Continue Lisinopril 10 mg once daily. 2. Referral to dietitian for nutritional assessment. 3. Schedule follow-up appointment in four weeks. 4. Order thyroid function tests. Thank you very much for the kind referral. If you have any questions, don't hesitate to reach out.